Mothers, Babies, Midwiives: With Woman in Kathmandu

Tag Archives: Birth Center

The staff meeting was to begin at 1:30. At 2pm people were beginning to gather. There seemed to be no agenda but we began. Everybody chatted and the agenda made itself apparent. Chapatis and spicey potatoes and cups of tea were brought in. People wandered in and out and at one point I thought I’d better give my prepared report on my visit. So I did. I wanted to avoid being rude and inappropriate, but the more I suggested the more they nudged me to be more direct. The staff received everything I said with such receptive kindness that it was humbling. Truly amazing how different behavior can be in another culture, and yet we really do understand and respect each other. There is something about the way things work here that is both frustrating and extremely refreshing at the same time. I will miss it. The slow pace is both pleasant and irritating by turns. Nothing happens and things surprise you and all of a sudden, it’s done. Birth can be like that too, can’t it?

I had my Dal Bhatt this evening, with the realization that I won’t be eating it many times more. I rode the bus on my 15 cent ride through the dirty streets knowing I would soon be breathing the marginally less polluted air of Texas. I walked through the throngs of pedestrians, narrowly missed by hooting motor bikers, knowing how much I would miss the street life, the noise and variety of Kathmandu in suburban Dallas.

Women are women, midwives are midwives, and birth is birth, but Nepali style it’s all a bit different, wonderfully so. Thank you Kathmandu. And lots of love.

The sun rose to another clear day and a clear view of the mountains the day after the elections. What would happen next? After breakfast, I got organized to head out to the birth center. Everything was…. normal. How interesting. No violence, no excitement, just life, busy streets and newspaper headlines that the elections were peaceful. Results were coming in. Record voter turnout. The maoists who led the stirkes had lost badly. But rather than responding violently to defeat, it seems they were licking their wounds and moving on. The marxist-leninists and the Nepali Congress are the 2 big winners with the vast majority of votes. The maoists, with a smaller number, hold the balance of power. Other parties have mostly 5% or less. All of this seems such a mature democratic outcome and brings a dose of optimism and confidence in the future that I think is in the air.

With the birth room redecorated, the childbirth education in place and the brochure at the printers, my work here is coming to a close.The anti-shock garment project sent me in and out of offices, NGO and Government, and I did two hospital presentations on its use.The new graduate level program in midwifery will hopefully start next year, It will be the first in the country and a prerequisite for the Midwifery Society of Nepal to have membership in the International Confederation of Midwives which regulates the profession worldwide. An initial research project would raise the prestige of the program and of the profession. It may really happen that it will be an anti-shock garment project. Kiran is for it. Dr Regmi, a big cheese at the Ministry of Health is for it and will fund impementation if initial funding is found. Doesn’t that sound like concrete progress? It feels good.

Meanwhile there was a funny day last week when the world seemed to be converging on APS birth center.Volunteers and staff were hauling around dusty piles of medical equipment, sorting, chucking, organizing. That frenzied, excitable mood that happens with a big clean was all around. Some of the senior staff who come in occasionally, Rashmi, Asha, Amala, were all there. And so were the Duggars! What? Yes father Duggar and Jill Duggar from the reality TV show about the family with the 19 biological children along with TV crew, invaded the festive cleaning up atmosphere of the center. For my non-US readers, know that even if, like me, you are barely aware of television and popular culture, you cannot help hearing about the Duggars and their TV tribe in the US. Jill D is on her way to becoming a midwife and while visiting Nepal, she wanted to visit a birth center, Nepali midwives and make an episode about her aspirations. Rashmi was interviewed. Mothers, babies and midwives were filmed. A festive mood prevailed.

While this was going on, the normal day at the center was happening too. A couple came in, for what they thought was an intial prenatal appointment at 29 weeks pregnant. But no heart-beat, and measuring many weeks smaller than 29 weeks. Sadly her baby was not alive. The couple were hugged and supported. Follow-up care was arranged. They had a a quiet corner of the center as the camera crew charged around. Sometimes events coincide in strange ways. Meanings are unclear but the strangeness implies meaning of some kind. That is midwifery in Nepal and everywhere.

Birth center chugging along. Feeling that my work there is finishing off projects: making sure the brochure is printed, getting new towel rails by the sinks (goal to encourage handwashing), discussing with Rashmi the placement of the new Ganesh statue. But my focus the last couple of weeks has been more outward and a bit outside my comfort zone: the anti-shock garment, hospitals, doctors, NGOs and Government administrators. Very different.

My first foray into the hospital world was a low key effort: Did a class for nursing students and faculty at at Tribhuvan University. It was a lot of fun. They were warm and enthusiastic. Here are some of the students having fun with practising labor support.

practising labor support

Tea with faculty afterwards

You may remember, that thanks to last minute donors I was able to bring a supercool neoprene and velcro device for stabilizing women who are in shock secondary to postpartum hemorrhage. Very enthusiastic about this simple thing that has been endorsed by the World Health Organization, has great outcomes in clinical trials but is virtually not used here in Nepal, where postpartum hemorrhage remains the number one cause of maternal mortality. So I put together a presentation on the device together with a bit of hands on training, and have been talking, telephoning, emailing, knocking on doors to spread the word. I have met some interesting people this way, and experienced lunch on the roof of the United Nations Fund for Population and a chauffered drive in a Government vehicle in which we drove through the middle of a preelection demonstration in Durbar Square. I did manage a presentation on the anti-shock garment at one of the hospitals, but whether I can really get a structure in place that will lead to training in use of the device, and incorporation into clinical practice is another matter.

Meanwhile, the elections took place yesterday and seem to have been largely peaceful with higher turnout than expected. The day was yet another holiday. This time the shut-down was total; a festive atmosphere of families wandering in the streets. Kiran, president of Midwifery Society of Nepal, invited me to lunch at her house where we talked for four hours…. all midwifery. went on the roof of her house to stare at the mountains through Russian communist era binoculars decorated with hammer and sickle. Ate dal bhat of course. Lots of tea of course.

I drew back the curtains one morning last week, and the air was clear. The mountains rose behind the houses. And there behind them… were the real mountains, the snow-capped Himalayas right outside my window. They had been hidden every other day by smoggy haze. Hooray, a clear sharp view of snowy peaks puts the smile on any morning face.

So through the city to the birth center. All is well. Things are happening despite glacial slowness. Why use one person to do something when 3 will do? Decide to go to buy the flooring for the birth room at last but wait there is a phone call then someone comes round with an important piece of paper to sign which involves much thinking and rereading and then of course there is another cup of tea and finally off on the errand we go. That’s the way it is. The task of getting the brochure printed is mammoth. Misunderstandiings about who is doing what and how it should be done… days pass. Leisurely dysfunction.

The story of Ratna sadly exemplifies the way it is in Nepal. She is a nurse with a few months’ midwifery training like most of the staff at the center. She wants to study more and finish her Bachelors in Nursing. Last week she told me that her grades weren’t good enough and she was on the waiting list. I commiserated. Today Rashmi told me the full story. Most applicants are wait-listed she said. Those that are accepted from the list are those who pay. Ratna can’t pay. Rashmi tried to use her influence, without paying, a little string-pulling but to no avail. No pay no place.

On a more hopeful note, I think I have found someone who will “champion” the non-pneumatic anti-shock garment in Nepal. It will need a champion to push its use, spread the word, inform, instruct, and cajole. Asa works part time at APS as well as full time at the big public hospital. She told me that she became a midwife because of her mother. Her mother died at the age of 33 of a postpartum hemorrhage. We weren’t talking about the anti-shock garment when she told me about her mother. We have not talked much. I am not sure why she told me about her mother. It was emotional and hard to talk about. Strange that she told me. Then I told her about the anti-shock garment. The anti-shock garment impressed her. She knows it will saves mothers’ lives.

And I want to tell all you deviners out there, Nepal is a place where it is apparently impossible to lose things because someone will find it for you. From my little flashlight which I left in a crowded restaurant and was returned to me 3 days later, to my camera which I lost at the Boudenath stupa and was returned to me by a delightful Nepali child. And a bag of precious goodies I had bought were carefully rescued for me by a guard at the Golden Temple in Patan.

The festival of Dashain lasts 15 days! The build-up was fun. There was the buzz of shoppers, travellers, preparation. Then there was the height of the festival: ritual, puja, tika, food. And then… it went on. Many shops still closed. Not much getting done. Personally, I had a case of Dashain fatigue. I wondered if the Nepalis felt the same. I had the feeling that some of them did.

I continued working at the birth center through the holiday. It was quiet but a bit of action here and there. Babies get born whatever is happening and the clinic is always open. But today the festival is over and despite being saturday which is the Nepali weekend, I had a much-anticipated meeting with Kiran at the Midwifery Society of Nepal and feel energized in new directions. We had a wonderful two hours together. She described her struggles for acceptance for the profession of midwifery and the resistance of both physicians and nurses (a sad and old story). She is working towards an in-hospital birth center (more like a midwifery led unit in the UK) which can serve as a model midwifery care site and as a clinical setting for midwifery students. We planned my continuing education topics. I will do a series of weekly hour-long sessions to the society through November. The first will be (surprise surprise) childbirth education and adapting teaching models to Nepal. The second will be on the topic of the anti-shock garment. Hooray! The third will be on birth centers and there may be a fourth on finding and using evidence for midwifery care practices. So lots of prep for me for those workshops lies ahead. Of course I continue to work with Rashmi and the midwives at APS Birth Center.

So now a few pitures. First shoving the sacrificial goats into a variety of vehicles!

I’m hanging out here in Kathmandu. I’m a routines kind of person. And I’m develping my routines. My quiet breakfasts. Organizing to go over to the birth center. What will I be bringing with me? What will we be working on? Wandering through the town to the bus. Last week or so I learnt that buses make sense. A cab is a bargain at $3 but it was my biggest daily expense! At 15 cents, it’s hard not to get a bus. And it feels a lot safer than a taxi. It’s bigger and it sticks to the bigger roads (much less picturesque and less bumpy). So it takes longer to get to the birth center. But I’m in no hurry. I love my wander/walk through Tahity (called Tahity??) and via a mini-monkey temple called Kathesimbhu Stupa

Kathesimbhu Stupa

and via the square with a temple that honors the tooth protecting deity

I think this is the tooth guy but not sure. Fierce anyway

and the veggie sellers of Asan Tole, and the crazy pre-festival shoppers, to Ratna Park where the foot traffic squeezes through a toothpaste tube and up onto the footbridge where people sit and sell flip-flops and watches, and a beggar plays listlessly on a drum and someone else is begging for a kidney transplant, to my bus. They squeeze us in cozily and off we go. Kalanki is dusty, dirty and busy. I walk a few minutes towards the birth center, and today before going in, I took a few pictures of the goat market opposite. Goats to be sacrificed for the Dashain festival

Today at the birth center, I was planning to prepare three topics for a meeting with Kiran, the president of the Midwifery Society of Nepal: 1) A presentation on Childbirth Education (I seem, bizarrely, to be becoming an “expert” on this topic) 2) A presentation on the anti-shock garment, it’s benefits, research to support it’s use in shock secondary to postpartum hemorrhage. I really believe in this thing and hope that Kiran will be inspired to push it to the Nepali Government and 3) Some topics in evidence based maternity care. I was supposed to meet with her at 3 and worked away at my prep but then she cancelled on me till next week. That’s kind of the way things go here, so I worked with the birth center midwives on posterior babies and other topics. We’ve had a good few days at the center. A Nestle man (boo, hiss) came to present on nutrition in pregnancy, and while we were all somewhat stimulated by some of it, I was also inspired to prepare my own nutrition power point! (of course). Here are some midwives listening to the Nestle (boo, hiss) man:

Here is more childbirth ed stuff: preparing material:

Prena and Laxmi

And here is a gorgeous Nepali lady smiling as she gets a depo shot!!!

And here are two delightful midwives bravely preparing to head home on their motor bikes

Don’t want to get too obsessive about my sleep in this blog, but it’s been a major feature of my life…. Trying to sleep. The night before last I slept very well. Halleluya. I awoke, excited to feel so good! My guest house includes breakfast and it’s 2 eggs, potatoes, tomatoes, mango juice, tea and 2 pieces of toast with butter and jam. Way more food than I normally would eat, but I have been eating it all! So I have my huge breakfast and get set on my way to the birth center.

The center is about 20 minutes away by taxi. The taxis are my biggest daily expense, $3 each way. The ride is wild, scary fun, nutty, indescribable but I will try. My street which connects Poknajol to Chetrapatti, is paved, although most are not. The street is full of walkers bicycles, scooters, motorbikes, pedal rickshaws, push-carts, stray dogs (many looking much the worse for wear) and the occasional cow as well as trucks and cars (mostly taxis) and workmen with handtools doing various repair jobs in the street. I hurtle along in my vehicle as we approach Chetrapatti which is a sort of a roundabout with a temple in the middle, around which rush vehicles and pedestrians in a wild dance of weaving in a variety of directions, horns blaring constantly. We dive out onto an unpaved lane that dips downward towards the filthy river. I can practically grab pieces of fruit or a piping hot chapati as we rush by. We careen through a variety of similar turns and bumps, pass along a wider road with many pedestrians stepping out in front of vehicles as they try courageously to cross the sea of traffic, duck under a huge rusty metal bridge onto the ring road, right down a small dirt track and we reach the birth center. Deep breath. Safe and sound. What a ride for $3.

Yesterday, had a short class on oxytocin and its various functions. Then Rashmi, the head midwife showed up. She is usually so busy, but was in relaxed mood, and we chatted a lot about birth center mangaement and her challenges. Then she took me out to a super wonderful dive where we watched the women making chapatis on the fire in front of us and ate them hot hot with a spicey bean soup. Followed by spicey tea mmmmm. Good! Then back to the center for some birth drills.

Today I did a bit of a lesson with a video illustrating midwifery model of care. Very hard to get discussion with these girls. They are not used to being asked questions by the teacher and are hesitant to give wrong anwers. There are no wrong answers!. They are shy but very willing. I bought us all lunch as a treat….. they had done well. After lunch we did some more birth drill stuff. Another good day.

Here are some of the lovely girls watching the video studiously on my laptop. (The laptop has a picture of my three boys. Prena has decided that she will move to Texas and marry Amos, the oldest)